Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr, Lake Worth, FL 33463 · Palm Beach County · 52 certified beds · avg 58 residents/day · certified since May 21, 1993
Part of chain: ELIYAHU MIRLIS (13 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 20, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 31, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 22, 2025 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Dec 20, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Dec 20, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Dec 20, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 28, 2023 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 28, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 28, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Sep 28, 2023 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| May 26, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 26, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 26, 2022 | B · Minimal risk, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 3 | 0 | D |
| 2023 | 5 | 0 | F |
| 2024 | 18 | 1 | G ▲ |
| 2025 | 1 | 0 | B |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $16,800.
| Date | Type | Amount / length |
|---|---|---|
| Dec 20, 2024 | Fine | $5,346 |
| Dec 20, 2024 | Fine | $11,454 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Florida avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.01 | 4.03 | 3.95 | top 37% in Florida; top 39% in the U.S. |
| Registered Nurse hours | 0.71 | 0.76 | 0.69 | top 45% in Florida; top 36% in the U.S. |
| Weekend total nurse staffing | 4.03 | 3.68 | 3.50 | top 17% in Florida; top 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.53 | 0.48 | top 49% in Florida; top 39% in the U.S. |
| Total nursing staff turnover (%) | 56.4 | 41.4 | 45.8 | bottom 14% in Florida; bottom 22% in the U.S. |
| RN turnover (%) | 75.0 | 46.0 | 42.9 | bottom 8% in Florida; bottom 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.28, RN 0.58, weekend 3.30. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 4445 Pine Forest Dr Lake Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2023 |
| Becher, Sarah | Individual | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2023 |
| Mirlis, Eliyahu | Individual | 5% or Greater Indirect Ownership Interest | 99% | 09/01/2023 |
| VRD 10 Hldco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2023 |
| Colman, Ruben | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2023 |
| Colman, Ruben | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Colman, Ruben | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Mirlis, Eliyahu | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2023 |
| Olazabal, Justina | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2023 |
| Olazabal, Justina | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2023 |
| Olazabal, Justina | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Olazabal, Justina | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Palm Beach Nursing Center | 0.7 mi | Lake Worth, FL | ★★★☆☆ | 2/5 | |
| Aviata at Coral Bay | 1.6 mi | West Palm Beach, FL | ★★★☆☆ | 2/5 | |
| VI at Lakeside Village | 2.7 mi | Lantana, FL | ★★★★★ | 4/5 | |
| Medicana Nursing and Rehab Center | 3.0 mi | Lake Worth, FL | ★★★☆☆ | 3/5 | |
| Beach Breeze Rehab and Care Center | 3.0 mi | West Palm Beach, FL | ★★☆☆☆ | 2/5 | |
| Finnish-American Village | 3.1 mi | Lake Worth, FL | ★★★★★ | 4/5 | |
| Terraces of Lake Worth Care Center and Rehab | 3.1 mi | Lake Worth, FL | ★★★★☆ | 3/5 | |
| Lake Worth Rehabilitation Center | 3.4 mi | Lake Worth, FL | ★★☆☆☆ | 2/5 | |
| Avante at Lake Worth, INC. | 3.6 mi | Lake Worth, FL | ★☆☆☆☆ | 1/5 | |
| Hamlin Place of Boynton Beach | 3.6 mi | Lantana, FL | ★★★☆☆ | 3/5 | |
| Aviata at Greenacres | 3.7 mi | Green Acres, FL | ★★☆☆☆ | 2/5 | |
| Aviata at West Palm Beach | 4.8 mi | West Palm Beach, FL | ★★☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
All facilities in Lake Worth →
Facility data as of CMS processing date 2026-08-01. CCN 105835.